Inspection on 27/04/07 for Woodford Care Home

This inspection was carried out on 27th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodford Care Home 21/10/08

Woodford Care Home 23/10/07

Similar services:

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Snydale Care Home

Hawkhills

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Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Woodford Care Home 594 - 596 Holderness Road Kingston upon Hull East Yorkshire HU9 3EU Lead Inspector George Skinn Key Unannounced Inspection 27th April 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodford Care Home Address 594 - 596 Holderness Road Kingston upon Hull East Yorkshire HU9 3EU Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01482 712639 F/P 01482 712639 S & M Care Homes Limited Position Vacant Care Home 23 Category(ies) of Dementia - over 65 years of age (23), Old age, registration, with number not falling within any other category (23) of places Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may provide care to one named service user on CSCI files in the category of MD 27/06/06 Date of last inspection Brief Description of the Service: Woodford Care Home is a large building situated on a main road on the outskirts of the City of Hull. There is easy access to local public transport and amenities. The home is registered to provide personal care for a maximum of 27 people. The registration category allows the home to care for people in the category of old age, not falling within any other category. The home has five single bedrooms and eleven double bedrooms. The home has two lounges and one dining room. The home has a quiet lounge that is also used as a library and visitors room. Accommodation is provided over two floors. The home has a small outdoor patio for service users to use when the weather permits. The home does not have a car park. Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection of the home since the new owners have taken over. As part of the pre-inspection process surveys were sent to all the people who live at the home, staff and relatives. This was to gain an over view of what people think of the home and how people experience living at the home. The responses to these have helped to form a judgement about the quality of the service the home provides. An unannounced site visit was undertaken to the home; the opinions of the people who live at the home were sought, some records were looked at, the building was looked at and observation of staff interaction with service users was assessed. What the service does well: What has improved since the last inspection? What they could do better: The new owners need to improve the records which are kept about the people who live at the home to help the staff meet their needs better. The new owners need make sure the staff are better trained to meet the needs of the people who live at the home. The new owners need to make sure that the people who live at the home can contribute to the running of the home. Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service experience adequate outcomes in this quality area. Service user needs are assessed prior to moving into the home Service users have not agreed any terms and condition when moving into the home. EVIDENCE: The home has been taken over by new owners since the last inspection, they have introduced a new Statement of purpose and service user guide, it was not clear if this has been given to the existing service users or any newly admitted service users. The acting manager stated that all the service users needs had been assessed prior to moving into the home, this was confirmed through the case tracking of Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 9 those newly admitted service users. The home has also developed their own care plans from these assessments. The new owners have drawn up new contracts/terms and conditions these are to be agreed with the service users or their representatives within the next few weeks. Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service experience adequate quality outcomes in this area. Service users health care needs are not adequately recorded in care plans. Service users can access health care professional when needed. Service users are protected by the home procedure for handling medication. Service users privacy and dignity is respected by the staff. EVIDENCE: The home continues to use the same care plans which were in place at the previous inspection. A requirement was made at the last inspection for improvement in the care plans to bring them to an acceptable standard. New documentation which is to be implemented on the 30th April 2007 looks as though it will address the requirement made. The staff have received training on how the new documentation should be competed and what information can be gained by completing the paper work. Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 11 The staff have received training on the administration of medication which has been provided by a pharmacist and further training is arranged. It was not clear whether this training was accredited. Observation during the inspection indicated that the staff understood what constituted good practise when administering medication. Prior to the inspection the allegation was made that a service user spends long periods of time in her room against her will; the documentation pertaining to the service users needs was looked at. This documentation indicated that due to her deteriorating mental health it was agreed that she should spend the majority of the time alone as she was very disturbed in the company of too many people and found it more peaceful on her own therefore being less agitated. It was documented that the staff should keep regular checks on her in the room and how this was to be performed to cause least disruption as possible. These actions were agreed with all relevant health care professionals following a best interest meeting. Observation made during the inspection indicate that the staff treat the service user with respect, they were sensitive to the needs of the service users and any conversation was respectful and staff practise was appropriate to the needs of the service users. Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service experience good quality outcomes in this area. Service users are able to participate in activities both in the home and in the local community; and have regular contact with their relatives. Service user can exercise choice in their daily lives. Service user received a well-balanced and wholesome diet. EVIDENCE: Outside entertainment is arranged on a regular basis, and in house activities continue to be accessed by the service users. During the site visit staff were engaging with the service users both in groups and on an individual basis. Some service users are able to arrange their own outings and activities and this is encouraged by the home. Results of the relatives survey indicated that they were made to feel welcome and were able to visit the home at any time; those who were visiting the home confirmed this. Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 13 Service users interests are recorded in care plans, new documentation documents this in more detail. Prior to the inspection allegation have been made about the quality and quantity of the food and the availability of choice for the service users. Observation made during the site visit confirmed that the food continues to be good and all service users commented positively, both those who responded to the satisfaction survey and those spoken with during the site visit. The service users are able to choose from a menu and the meal times are as flexible as possible especially breakfast. The cook commented on having plenty of provisions to use; the meal on the day of the site visit looked appetising and well presented and service users commented positively. Staff assisted service users sensitively and the service user set the pace. Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service experience good quality outcomes in this area. Service users are protected by the homes procedures for dealing with complaints. EVIDENCE: The home’s statement of purpose contains details for making a complaint, and a complaint procedure is posted around the home; this is also available in the service user guide. This includes information on how to contact the CSCI. Service users spoken with said they would talk to the acting manager if they had concerns and they were confident that this would be taken seriously. A complaint record is maintained and complainant signs to confirm they are satisfied with the outcome. All the staff spoken with during the site visit confirmed they would know what to do if they suspected any form of abuse was taking place; they were very clear that they would not tolerate any forms of abuse and they would report to other authorities if they were not satisfied with the acting managers or the owners response. Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 15 There has been no training for staff with regard to the protection of vulnerable adults, the acting manager is intending to book this for staff to attend in the near future. Since taking over the ownership of the home the owner has had to deal with many complaints which have been received via the CSCI, this has been done professionally and has resulted in positive outcomes through addressing effectively those concerns raised. Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service experience good quality outcomes in this area. Service users live in a home which is well maintained and clean. EVIDENCE: Since taking over ownership the new owners have decorated many parts of the home, responses from relatives surveys indicated that there has been an improvement in the physical environment. Observation of the building confirmed that some redecoration had taken place since the last inspection. Those areas that had been redecorated showed a marked improvement. The owners have applied for a grant to improve carpets and other aspects of decoration. Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 17 The owners have undertaken a risk assessment for each service user to establish if service users want or are able to be safe with the provision of lockable bedroom door. Those who have been assessed as being safe have been identified and locks are to be fitted to their doors. Generally the home was tidy and clean and the service users commented on being satisfied with their rooms. It is recommended that the owner produces a plan of refurbishment which sets time scales. Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use the service experience poor quality outcomes in this area. There is not enough staff on duty to meet the needs of the service user staff lack the training to meet the needs of the service users. EVIDENCE: The registered provider must comply with the staffing levels recommended by the Staffing forum Guidelines for residential homes issued by the department of health. Based on the dependency level of the service users provided in the Pre-Inspection Questionnaire (PIQ) the total care hours per week must be at least 482.92. Information provided in the PIQ indicates that the home provide 445.50 per week this means that there is shortfall of around 40 care hours per week. The level of induction training that staff relieved was varied and some staff have received very little mandatory training since working at the home. Some staff are registered to commence NVQ training in the near future 6 staff have already achieved the NVQ qualification. The care staff were knowledgeable about the service users needs and they cared for the service users with respect and maintained their dignity. Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 19 Interviews with the staff indicated that information was passed on an informal level between staff and there was a lack of formal training. The homes recruitment and selection procedures protect the service users. The home need to make sure that all staff have received mandatory training soon after commencing employment and this should be updated as required. Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use this service experience poor quality outcomes in this area. Service users live in a home which is well managed but the manager needs to be registered with the CSCI. Service users need to have the opportunity to participate fully in the functioning of the home. Service users wellbeing is not safeguarded due to the lack of staff training. EVIDENCE: The registered provider needs to make application the CSCI for the registration of the acting manager as a matter of priority. The acting manager had a good relationship with the service users and displayed a good working knowledge of Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 21 their needs she was committed to the development of the home and has done some good work with the staff. The owner has used surveys to establish stakeholder views and has conducted service user meetings; this needs further development to become an effective quality assurance system. The service users continue to be protected by the homes financial procedures. Evidence indicated that staff had not received all of the mandatory required soon after commencing employment and this is not updated as required. Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 1 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 4, 5 & 6 Requirement The registered person must develop contract/terms and conditions must be agreed with each service user. This must include all those areas referred to in standard 2.2. Timescale for action 30/09/07 2. OP7 15 New time scale previous time scale not met (30/10/06) 30/09/07 The registered person must ensure that a service user plan is developed for all service users that detail fully all aspects of the health personal and social care needs. Generic and specific risk assessments must be completed. This must be done with the service user or their representative and reviewed at least monthly. Previous time scales not met (30/03/06, 30/10/06) new time scale given 4 OP27 18 The registered person must ensure there are enough staff on duty to met the needs of the service users DS0000068471.V337880.R01.S.doc 30/09/07 Woodford Care Home Version 5.2 Page 24 5 OP28 18 6 OP30 18, 19 7 OP32 4, 12, 24 & 26 4, 5, 6, 14, 15, 17, 21, 22, 24 7 OP33 The registered person must ensure that the staff are appropriately trained to meet the needs of the service users. The registered person must ensure that all staff receive appropriate induction training to met he needs of the service users and fulfil the aims of the home. The registered person mat ensure that visit required by virtue of regulation 26 are undertaken The registered person must develop a system of quality assurance which ensures the service users, and all other stakeholders to the service, has an input into the functioning and development of the home. 30/09/07 30/09/07 30/09/07 30/09/07 8 OP38 New time scale set, previous time scale (30/10/06) not met 10, 12, The registered person must 13, 16, 17 ensure that staff receive & 37 mandatory and specific training. Previous time scale not met (31/12/05, 30/10/06) new time scale given 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP19 OP31 Good Practice Recommendations The registered person should produce a program of redecoration and refurbishment and provide a copy to the CSCI The registered person should submit an application for DS0000068471.V337880.R01.S.doc Version 5.2 Page 25 Woodford Care Home registration for the acting manager. Woodford Care Home DS0000068471.V337880.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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